What medication should be given to a Multiple Sclerosis (MS) patient on teriflunomide for diffuse body aches?

Treatment for Diffuse Body Aches in MS Patient on Teriflunomide

For an MS patient on teriflunomide presenting with diffuse body aches and no other symptoms, acetaminophen should be the first-line treatment, not tizanidine. 1

Why Not Tizanidine

• Tizanidine is specifically contraindicated for diffuse body aches without documented muscle spasticity or increased tone 1
• The American Academy of Neurology explicitly recommends avoiding tizanidine for diffuse body aches when spasticity is absent, as it is indicated only for chronic daily headache/migraine prophylaxis and muscle spasticity with documented increased tone 1
• Using tizanidine in this scenario represents a common prescribing error that should be avoided 1

Correct Treatment Approach

Step 1: Characterize the Pain Type

• Diffuse body aches without neurological features (no burning, tingling, or shooting pain) indicate musculoskeletal-type pain rather than neuropathic pain 1
• The American Academy of Neurology emphasizes determining pain type before selecting treatment, as this fundamentally changes the therapeutic approach 1

Step 2: First-Line Treatment Selection

• Acetaminophen is the initial choice for non-neuropathic body aches in MS patients, as recommended by the Mayo Clinic 1
• This differs from neuropathic pain, which would require pregabalin or gabapentin as first-line agents 1, 2

Step 3: If Inadequate Response After 4 Weeks

• Consider pregabalin or gabapentin if pain has neuropathic features 1, 2
• Alternatively, consider duloxetine or other SNRIs for mixed pain patterns 2
• Avoid polypharmacy without trying monotherapy first—trial single agents for at least 4 weeks before adding combination therapy 1

Critical Pitfall to Avoid

• Assuming all MS pain is neuropathic leads to inappropriate treatment 1
• Diffuse body aches without neurological features respond better to acetaminophen than neuropathic agents like pregabalin 1
• NSAIDs should be avoided for chronic pain management in MS patients with fibromyalgia-like symptoms due to lack of efficacy and potential side effects 1